corner and we have a bright future. we can promise our fellow americans we have a bright future. andre going to sit here you're going to walk out of here and there is going to be another v.a. panel. there have been dozens that will come in and give us to answers. either you're not telling the truth or they don't have the answers to the questions that we asked. that is going to happen again tonight. if it doesn't happen i will be shocked. there are dozens of high-ranking members of the v.a. that come in here and have nothing. phoenixion is if the facility was at the apex of this urgent reaction, one of the things that has floored me is the lack of urgency on the part of the v.a. that there is a five alarm fire and nobody is rushing to put it out.

phoenix v.a. and i was responsible for any of what is going on the minute this hit the fan nationally i would be looking and trying to figure it out doubletime and make sure that my facility is the standard and that we raise the standard and that we reset the record and we are ace an example for the rest of the country. this committee has said we will not tolerate this. we are going to provide the best health care to our veterans. have you seen anything that says what a turnaround. people have been fired. there is a ton of accountability. have you seen anything about this in the last? >> the turnaround i have seen is in scheduling. the backlogs of been reduced. patients of gotten phone calls from the v.a.

they have done tremendous work getting veterans cross test. the problem is they only fix the problem that was in the media. they haven't fixed the patient care problem. they are working on that for the satiety department. they're a are still administrators that refuse to address nursing retaliation. five or six of the full-time physicians told chain of command this. they said that they would not investigate the backlash against dr. mitchell. >> we had the inspector general and in here a couple of weeks ago. that the issue of brunette corruption is going on actively. until somebody goes to prison and people are fired. there is tangible action taken.

your colleagues that you work with feel like their backs are covered. if it took you see, a national urgency to move the scheduling urgency and it took resilience on the ranking member to go after this issue and try to reset it. how long do you see if we keep rusher up, if we don't read the corruption the new secretary will be more successful. how long will it take to turn this around if we keep up the same amount of pressure? >> i don't know if i'm in the best position to judge that. attention topaid the scheduling issues and i get completed within 10 minutes, the media needs to pay attention to the lack of ethics issue. >> i want to say that we've got to do two things. we need a separate group to look

at the a. when a new secretary comes in, we'll have to deal with the health care issue first. they won't have time to become the chief of police for v.a. and also make the health care reforms. you're going to have to have some wrist -- assistance. the next thing you have to look at is performance standards for leadership. unlike those my colleagues who look in medical facilities, they may have legitimate reasons for their challenges. our organization the primary function is to enroll veterans into health care. this is not about the politics of the law. this is about v.a. having a public affairs division in d.c. n outreach office here

in d.c.. that predicates and down to atlanta with the purpose of a senior executive reaching a performance goal. it had nothing to do with our business. have 600,000. that rivals a number of people that rival enrolling in v.a. in a year. imagine a years worth of applications in a pending status. 600,000 deposits go in on monday and we never hear about them for another year. and you think the walls of that bank would still be standing today? the minute women who sacrifice for this country have to deal with this. we focus on nca. we create marketing material for delta dental and metlife. we give at the same little flyers in a post office or a grocery store let people know that if you have a pending

, contact such and such number. the same effort we put into bonuses andership the same interest we put in attaching ourselves to high profile projects is the same amount that needs to go to veterans. i encourage you guys if nothing else, make sure remove to a system that has more data integrity and require the people who come here and soon these panels to sign off on the information they turn into congress. when they come back they can't say that the report was somebody dumb -- done by somebody else. you tommy muska chairman. mr. jolly, you are recognized for five minutes. >> what is the relationship between ucla and the los angeles va hospital? facility, it is a

public institution. a number of the physicians and surgeons have joint appointments counterparts within the university and with the v.a. you are a very egregious case. my colleagues comments with admiring your trilogy -- courage. was with thet board of regents of california and not with the v.a.? >> it's a complicated case. we agreed to part ways. there isve noticed, tremendous overlap and there is a federal component to that. >> here's my question and i am

trying to distinguish between the pattern and the law. o wasncident your for t referred to as a ucla party. was it strictly a ucla party or was it also of the a institutionally involved? >> there were a number of members who are employed as physicians at the ba -- v.a. a component of that was directly related to an investigation that occurred at the v.a. led tofacts of the case a settlement with the board of regents of telephone it. to the facts supported claim against the v.a. and the lauper headed you from filing some sort of legal action against the v.a.?

was the pattern specific to ucla and not to the v.a.? the state comment on component of it. >> this is my question. it is a significant case. do the fax soul he lead you to litigation against ucla or does the lauper haven't -- lauper haven't somebody in your position to get redress from the v.a.? >> the law allows we to seek redress from v.a.. there is a state and federal component. >> your settlement was on the stateside. >> correct. >> are you familiar with the stop the line program? it is something i have seen. it is interesting that you're not. myis been highlighted by local va hospital.

it says that for anybody from a custodial staff to the doctor, if they see send the interferes with the delivery of patient care at any level it is a stop the line. ability toe has the stop operations immediately out of concern for something they might see. i know it has been adopted any number of different facilities. none of you are aware of this? >> i am not. >> i will be honest with you. it was promoted to me as an effort by the v.a. to encourage every employee to step up and say there is a problem. each of you who already step forward in a whistleblower capacity and you have no knowledge of the program which says to me it is not as promoted internally as some would suggest it has been. i find that very disturbing.

>> thank you, mr. chairman. i yield back. ahead tod like to go the next panel unless some he has a burning question that they went to ask. thank you very much to the witnesses. courage itciate the took to come here tonight and we will be watching. us, weof you contacts will jump to protect you from any further retaliation at the apartment. thank you for being here tonight. [applause] our second panel we will hear from carolyn lerner. she is accompanied by mr. eric bachmann.

v.a., we will hear from the acting principal deputy under secretary for health. he is accompanied by the deputy inspector in the office of the medical inspector. if you would, please rise again before you get too comfortable. raise your right hand. do you solemnly swear under penalty of perjury that the testimony you provide is the truth? thank you very much. take your seats. your first complete written statement will be made part of the hearing record. you are now recognized for five minutes. >> thank you.

committee, thank you for the opportunity to testify about the office of special counsel and the work with whistleblowers at the department of veterans affairs. i am joined by eric bachmann who is supervising the efforts t protect employees from retaliation. i want to acknowledge the many employees at the office of special counsel who have been working tirelessly on all of our v.a. cases. there are too many of them to identify by name. several of them are here with us this evening. my statement will focus on three areas. of specialrole counsel's office in relation to whistleblowers. second, a review of current caseloads. third, some signs of progress. this is an independent agency. it has jurisdiction over 2

million federal employees. we have a staff of about 120. we have the lowest budget of any law enforcement. disclosures using a very high standard of review. if the standard is met, i sent it to the head of the appropriate agency who in turn requires to investigate and sends a report back to me. it was within this framework that we received and are still receiving dozens of disclosures from v.a. employees from across the country. the office protects federal workers from primitive personal practices, especially retaliation. we conduct investigations and determine if retaliation occurred. turning first to whistleblower disclosures, rather than using the valuable information

provided by whistleblowers as an early warning system, the v.a. often ignores or minimizes problems. this approach has allowed serious issues to fester and grow. in the numerous cases before our agency, we see a pattern where admits to serious deficiencies in patient care yet denies any impact on veterans health. the impact of this denial is to hide many of the issues which only recently come to light. my written testimony provides several examples. i want to highlight one egregious example. the report substantiates a -- allegations a to veterans with conditionshiatric

left seven and eight years to get mental health treatment. theypite these findings, denied the said any negative impact on patient care. this conclusion is indicative of many of the cases we reviewed and reported on. the turning now to retaliation cases, we have received scores of complaints from employees alleging retaliation. we have six to seven active investigations into retaliation complaints. these plates come from 28 states and 45 separate facilities. the number increases daily. 1, we have received 25 new complaints. in addition to these ongoing investigations, we are taking several steps to as -- resolve complaints. a priority and take ross s four v.a. cases.

in an effort to find ways to work constructively with the v.a., we have met with many officials including acting secretary gibson. i think it is important to note the encouraging recent finds we have from the leadership. therapies to be in a willingness to listen and concerns. they want to act on them appropriately and ensure employees are protected for speaking out. when i met with secretary he is committed to protecting whistleblowers. andould take away the need help whistleblowers. it will also send powerful messages to other v.a. employees that if they have the courage to the v.a. willing, protect them from retaliation. inspeaking out.

these problems would not have come to light if not for the information they have provided. withok forward to working the whistleblowers and the v.a. to find solutions to these ongoing problems. we look forward to answering any questions the committee may have. >> thank you. dr., you are recognized for five minutes. >> thank you and good evening. i know i come here tonight with my credibility in question. there is no doubt about that. i have some prepared remarks but i would rather just speak my mind. we failed. in the trust that america has

placed in us to fill our mission. patients have clearly waited too long. agree with congresswoman kirkpatrick that it took a whistleblower and a crisis to expose the events and get us focused on correcting those deficiencies. as i said and listened to the first panel, i was disheartened that staff feel that they cannot fix problems in the organization and affect safety, quality, our business integrity. i think this is unacceptable. the acting secretary has made it clear that this is unacceptable. employeesmemo to all on june 13 indicating that kind

of behavior was unacceptable and we would not tolerate retaliation. the stories i've heard tonight depict a broken system. believe that these things are exceptions and not the rule. goodw there are many employees in this organization who work tirelessly on behalf of veterans. there are many managers and executives within the organization the to the same. that forart of it is every whistleblower who comes forward and says something, someone is quiet and tries to make an effort and goes away. leave risks in our system and deficiencies that are not fixed. i apologize to everyone of our

feel they have been silenced and their passion has been stifled. that is not acceptable and it is not what i stand for. i am past been upset and mad and angry about this. i am disillusioned and seconded by all of this. believe that i am at a point in the organization. i left private medicine to come to work for the v.a. i did that because i thought there was no nobler mission or greater devotion than what i am doing. i did not come to work for a mediocre health care system. i came to work for one of the best health care systems in the country.

i believe it can be the best health care system in the country once again. the problems we have can be fixed. we went through one of the greatest transformations in the health care industry in the 1990's. it we were a great system. i have hope and confidence that we can do that again. that really concludes my remarks. i promise you we will do our best to answer your questions. your comments.r there are a lot of things we to cover. i was looking over the testimony of the osc where they describe v.a.ssue at montgomery where in fact a physician

instead of writing accurate notes for a given patient was confirmed to have copied and to 1200 and 41 separate records. he still works for v.a.. explain how that can be? into are ongoing investigations in a number of areas run the country by the omi and other entities and law enforcement. there are potential issues around privacy and the rights of employees and patients here. most of these issues are very complicated. guessingbe better us notes in the brief. >> it may be better for you.

it is not better for this committee. i have not identified anybody by name. we have not divulged any patient names. do you accept the fact that osc says that they found where a pulmonologist did in fact do this? >> i don't dispute that. >> how in the world can this person still be employed at the v.a.? >> i would say this. i think that we are very interested in the quality of care in the v.a.. that documentation is an important part of that. it is a common practice to take historical information from prior notes and use that information. that does not change. we don't copy and paste material from old records into new

records as evidence of the current encounter with the patient. we would not tolerate that. we would not support that. represent clearly inferior patient care. could you comment on what is going on? >> there is a theme that we see that there is an investigation. the omi confirms the allegations. they say it is not a problem. alabama, this is happening with a doctor who discovered that another physician was cutting and pasting patient records. these are things like vital signs and treatment plans.

this is important information for the surgeon to have before he operates on someone. he discovered this physician was cutting and tasting. omi substantiated. recordsver 1200 patient that were involved. sortput that physician on of a review plan. there is a specific name for it. i am forgetting what it stands for. they did a review while he was on that review. he was still cutting and pasting. instead of taking disciplinary action against the physician, the f tpe. no disciplinary action was taken. this fits the pattern that we're concerned about. confirmed and no

harm is found to haitians -- patient's health. no corrective action is taken against wrongdoers. that is what i think needs to be fixed. who is luckier? the veterans that didn't get harmed? i can answer that question. the cuttingay is and pasting of information misrepresents things and would not be acceptable. it is not acceptable to us. to come and discuss those details. there is an issue of harm. briefingomi does their and puts up their reports and

says they found no harm, i have looked at some of these cases. while there might not have been any evidence that someone was actually harmed by the process, i don't think that means we as an agency would say that what happened was appropriate. i think those are different things in terms of the omi's work that they did. don't interpretate that i don't that as necessarily condoning appropriate behavior. you that byubmit to this worsened still being employed at the department of veterans affairs, it does give

the signal that it is an appropriate thing to do. >> i understand. much, mr.ou very chairman. acting secretary gibson has a restructuring of the medical inspector in order to create a stronger internal audit function that was insured that issues of care quality and patient safety remain in the forefront. what you believe is the primary mission of omi? >> it was set up as a quality improvement process within the organization. i think that it is clear in respect to the osc cases. they were done prior to this in a different way. the quality of those reviews improved tremendously. i think everybody agreed to that.

today, i think we realize that we need a different function within the organization. that is this kind of quality control and audit function that is been proposed. i can tell you today that the omi calls are going to the oig. they are not taking new cases in this interim. issues are now being handled by a team of people at department level that report directly to the secretary. i think the organization is trying desperately to address the issues that are there and with respect to doing these investigations.

the secretary has made it very clear that not only will we expedite those investigations but we will pick disciplinary action or hold people accountable. employees will be added to create this audit function? planson't believe the have not been entirely formulated. adam have an answer that question. -- i don't have an answer to that question. release vowing to restructure the office of medical inspector address the issues you have raised regarding responses to complaints to your office has forwarded? >> that is a tough question to answer. we don't really know what the restructuring is going to look

like. i am encouraged. i am encouraged by statements made to me personally by the acting secretary. i am an optimist. i think it is very possible to make improvements. at an early answer to your question. i think time will tell. would we ensure that the recommendations and results of investigations undertaken by omi are acted upon? for a long time taken the recommendations of the findings of the omi and we find

facilities that develop plans with corrective action. they have those plans and they are tracked. i think one of the things we need to do going forward in this theess is to tighten up various steps of the process from discovery and investigation to action planning and accountability in a much tighter way. been distributed over different silos within the organization. it is system like that, prone for things to fall through the cracks. i think part of a process is beginning to tighten those things up. they are drawing a clear line through them. on chairman up miller's point, how will omi achieve real accountability? think omi itself, i don't

know that it will be doing this work ultimately, the omi itself will will not be responsible for the accountability part. that is a management function that requires its own set of to do the to be able fact-finding and look at the evidence and say this is an appropriate disciplinary process. that needs to happen swiftly. it needs to happen systematically but also with fairness. >> thank you. arer. lamborn, you recognized for five minutes. >> you heard my question for dr. mitchell and her responses. veterans health in phoenix was compromised because her warnings were not heeded even to the

point of patients dying. she was retaliated against to make it even worse. how can we strengthen the whistleblower statutes that are already on the books to better protect whistleblowers like dr. mitchell in the future? the whistleblower protection enhancement act has all of the elements that are necessary to protect whistleblowers. it has to be enforced. it people need to feel comfortable coming forward. the employer needs to create a welcoming environment for whistleblowers. they need to welcome change that whistleblowers recommend. our agency enforces the whistleblower protection act. place.ucture is in

whistleblowers can be protected. i think robust enforcement is important. changes iositive what would recommend making to the act. if it is not working as well as it was intended to work and you just said it needs to be better enforced, what has to change in the culture of the v.a. to prevent these problems from happening in the future? >> one step is the v.a. can become certified under section 2302 the. government -- implement, i have gotten a commitment from acting secretary gibson to have the v.a. become certified under that program.

it requires more training for new employees and training for existing employees. you have posters in the facility. having a link my agency's website on their website. but it is a good first step for the v.a. to take. another is for the v.a. to take some expedited actions once retaliation cases are before us and if we are working on them to try to resolve them. not having to go through a willnged investigation send a positive message. it would put some meat on the bones of the promise not to tolerate retaliation. i am very hopeful that that will happen. it will be a positive step. there are other things that agencies do with they have a problem with culture. we have worked with many agencies. one that comes to mind is the

air force. serious complaints about retaliation at the mortuary when there were allegations about lost body parts and misconduct happening. we heard repeatedly from whistleblowers of the culture was very bad. once the air force decided to take steps to improve things and change the leadership and send a strong message to its employees, we got reports back that things were much better. i don't think this is an insurmountable problem. because the v.a. is so big it will require a lot of effort to train supervisors at the regional level and how important is not to retaliate in value the information that we're getting from whistleblowers. >> if you want to wade into this, there is legislation that the house is passed making it easier to fire people.

that would send a very powerful signal. even if it is just the threat of that being available. >> i have not reviewed that legislation. i don't feel comfortable commenting on it. it does not require firing. what we are seeing is not even minimal disciplinary action. i don't think it requires termination, although in some cases it probably does. if there was a structure in place for that kind of disciplinary action, we have not been seen a lot of it. i don't know that legislation is necessary rather than just enforcement of the law as it exists today. >> thank you very much. i yield back. >> you are recognized for five minute. that the civilng

service protections are not so onerous? >> you can be terminated for misconduct under the federal civil service laws. there is a current framework for doing that. reason, it isr just not happening at the v.a.. can you speculate as to why not? are people not trained? extraordinary for a collie too turn on another colleague. -- colleague to turn on another colleague. the caave one case where is taken disciplinary action in a retaliation case. it is impossible not to do it

all. there has to be a willingness to do it. what we have seen for the most part in our cases is people are not disciplined or if they are it is a mild discipline. what is going on at the v.a. in terms of why they are not doing that, i really can't say. it is certainly possible. we have seen it done. >> i am just curious. this case of the dr. copying and pasting. i have heard general positive reviews. some people outside the v.a. say it is incredibly user-friendly. there can be pages and pages and finding relevant data is difficult. one doctor that i spoke to recently evaluate records for the courts for the purposes of

determining whether people are eligible for ssi disability. records fromll get the v.a. that will be like a phone book. systems in the private sector are much thinner. he has to go through pages and pages and pages to get the relevant information. is there some truth to this? is part of the reason why this dr. was able to think he could get away with this because there is a vulnerability in the system? >> when you print out charts, they may be think. are patients have a tendency to have multiple visits. they are sicker than the average private patient. computerized record system, i can talk about what is a

common practice. if i am seen a patient and i need to put into the record the patient's problem list and list of things wrong with them and their past medical history and when, they had surgery or were hospitalized those facts don't change. it is common practice on paper to look at the chart and rewrite those things on a new note. system, youecords can copy that section and pasted. if someone is not careful they may capture more things than they need to. i am not saying that is what happened here. happeneddefending what in this situation. i am trying to explain a common practice and what could happen. i want to say couple of things. elements of the was a bladder -- whistleblowers

certification program in place. we had training for a long time. i think the secretary has made a commitment to having that. we have had discussions about that. we want to do that. i think that accountability and we have heard a lot about culture, you can change structure and processes and people. in the end it is about leadership and accountability in the organization. i think that is the commitment that secretary gibson has made. it is the commitment i am making tonight. one of the biggest issues that i have heard tonight is people who felt like they suffered while the process was being resolved. i would make a commitment tonight, i will give you my cell phone number and you can call me will intervene for you.

>> thank you. you are the second person who has given me your cell phone number. i am getting that message and i am encouraged. >> my time has expired. >> he didn't say he would answer his cell phone. [laughter] mr. vice chairman, you are recognized for five minutes. >> i appreciated. employees had been placed on administrative leave anderminated for falsifying negligence? >> i can't give you a number tonight. inan tell you that we have some of these specific cases

action plans those and where there was administrative action recommended. we have taken him in a straight of action in those cases. >> you can't give me a rough estimate? can you get that information? >> we can get that to you. many employees have been placed on administrative leave or terminated for actively retaliating against whistleblowers? >> i would have to get that for the record. how many whistleblowers have been placed on administrative leave reprimanded or terminated for attempted to expose misconduct within the department? can you give me a rough estimate? >> i don't have that information. i can tell you that we have complaints from 67

whistleblowers right now that are active in our agency. deputy mr. to my bachman and see if he can add to that. >> i don't know if we have a specific number. have at least three whistleblowers who have come forward recently that osc has been able to get. and almostorward immediately they are hit with a 14 day suspension. we have contacted the v.a.. to staypersuaded them those actions while osc investigates. that is one role that we are able to play in all this. i would be happy to go back and check our records and see if we can find exact numbers for you in terms of administrative leave and other disciplinary actions. >> are there more whistleblowers reprimanded than those who have

misconduct and negligence treating our veterans? >> if you're asking is do the whistleblowers suffer adverse consequences? someoneso than maybe who is committed negligence or malpractice? >> item of the goings-on. >> anyone on the panel? >> and the decadence of the question. >> i would like to get that information as soon as possible. when cases are referred to the osc and claims have been substantiated, what disciplinary action is taken? one of the things we look for when we get the agencies report

is what disciplinary action has been taken. in most cases we have reviewed there has not been any disciplinary action taken. i can't give you exact numbers. it is the exception and not the rule. one less question, what consequences were those who giving false information facing? >> i don't know if i can answer that question specifically. we do believe the disciplinary action is taken, there is a set of criteria that depend on the egregiousness of -- >> let me give you a hypothetical case. >> i don't know if i will be able to make up a hypothetical case. there is a table of penalties that exists. that is judged by what has

happened before. the intention of disciplinary action is not to be punitive. change theded to behavior of the employee. behavior,t change the separation is what has to happen. that is usually the end result of a series of ross. >> if they give false information to the oig, that would be criminal. thank you very much. i yield back. i would like to have that information as soon as possible. arer. brownlee, you recognized for five minutes. >> you spoke about the whistleblower row graham and certification. can you tell me why the certification program is an optional one and why it is not

mandatory? >> it is mandatory. issued anhe president order requiring agencies to go through that process. the plans for doing so are posted by june of this year. i don't know why it was made a voluntary program. we started the certification program in the early 1990's. not a lot of agencies a been certified. >> did the v.a. comply with that by the deadline of june or are they saying now they will go through the steps for certification? >> i don't know if there plan has been posted. i don't think that it has. they said they would be doing so very soon. weill try to follow up and >> will verify for sure. we will help them become certified.

i cited certificate for every organization it comes through. i know when they reach that milestone. our panelistsom earlier today. their identities were compromised in the process of .orking with the can you give me an idea of what your office does? what steps are taken to ensure protection of a whistleblower? >> if someone comes to us with a disclosure, they have the option of remaining anonymous. -- if they choose not to don't doonymous, we independent investigations for disclosures. once we make a finding of

likelihood, we review the agency's investigation for reasonableness and report to the president and oversight committee in congress. step on keeping information confidential is asking the whistleblower if they want to remain anonymous. when we refer a matter to an agency, we remind them of the need to protect the whistleblower. they have to protect that person from retaliation. in order to do a full investigation, you have to speak the whistleblower. one problem we found is often the investigation they don't talk very thoroughly or interview them. that is a problem in and of itself. the whistleblower is the subject

matter expert. they have to speak to the whistleblower to get the full picture. to do any hard investigation without disclosing identity. >> part of the certification program will help enforcement and terms of the protection piece? it doesn't directly involve enforcement. did make sure is that supervisors are trained and knowledgeable about their responsibilities when someone does come forward and reminds them that retaliation in all forms is unlawful. i do think it would have the derivative effect of serving that purpose. >> thank you. understand you are new to this position. the vha formerly with

in their transformation efforts. i presume that means the v.a.'s transformation. fromjust curious to know your old position, how you thought you were doing with the transformation of the aj? of any of those things? >> i was not aware. i think most people in the organization at senior levels were unaware. i think that is part of the problem. my job as transformation lead for the organization, we have omitted a program and expanded our health program. those are the things i was working on. i was a medical center director for 12 years.

i have a lot of operational experience. i thinknto her point, training and education is very important. people have to know the right standard of conduct is. the second point i would make is once they know it makes it easier for us to hold people accountable. you can't say i didn't know. think that program has the potential to have a very positive impact. >> doctorow, you are recognized for five minutes. of things tot patients that require one thing that is very important. that is called trust. washave said the v.a. great. i have a v.a. a mile from my home. a lot of good people are going to get up in the morning and go to work.

through all this investigation, we lost trust in the v.a. how can we trust anything the v.a. says when we have panel after panel and tell us these egregious things that have occurred? make almost impossible to a politician speechless. when you have to severely mentally ill veterans in the a second veteran first first but his comprehensive psychiatric untiltion did not happen 2011. how in the world in a health care system in america could that happen system in america cd that happen anywhere? and let me go on. no medication assessment or modification has occurred in 2011 when another doctor came

along and reevaluated this veteran. despite these findings, the omi would not acknowledge that the confirmed neglect of residents at the facility had any impact on patient care. typical answer is a harmless error, in some areas the veterans could have been better taken care of. not like it ignored for eight years. but the omi is not feel their patients rights were violated. how in the world with a straight face can you do that? then back to the chairman, just a moment ago when this person was pasting and cutting and all that, that is someone who is dishonest. -- andhave a consultant i have been to the operating room thousands of times -- i have got to know what they are telling me is truthful. i can promise you this -- if that had occurred in my practice, they would have been fired on the spot. if we found that out in our

hospital where i practiced for over 30 years, they would have been fired on the spot. what we are hearing is that the people, the whistleblowers who bilirakis up, as mr. just said, suffered more consequences than the people who do the egregious act. i don't understand that at all. can you enlighten me? >> quite frankly, i am speechless. i am appalled. i don't know what else to say. i can tell you that i don't that thatof us think is acceptable for a patient to be in one of our facilities for eight years and not have a major psychiatric exam except once. i cannot defend it. >> it is beyond comprehension that not one but two veterans --

i know you said this a moment ago, but we have -- the oig brings information up here. if someone knowingly lies to the oig, you should not have to go any further. you're dealing with a liar. you should not have to go any further than, "you are out of here today. you are fired." right now it does not appear the v.a. is doing that. we cap dance around all these things. let me ask one other question quickly. my time is about up also. how can you -- and i know you are new in this decision -- undo the damage you have done to positions and others whose careers have been damaged by this? what do you do to repair their reputations? >> i don't know the answer to that. in some cases the damage clearly has been done. we clearly owet

some people an apology. i think we need to figure out where we can make people whole. we try to do that. i think the most important thing is that we have to go forward. i cannot undo the past, but i can do something to change -- >> i appreciate that, and i feel very badly for the people who will go to work tomorrow at the v.a. who are doing a good job and are working hard. let me tell you who needs an apology -- the two veterans who were mentally ill and their families who were completely ignored, and the 141 people who had something done to them at the v.a. night whenf cases at we would turn over duty and you would take the beeper, now the cell phone. you expected your partner to tell the truth because folks'

lives depended on it. these are not games we are playing, these are people's lives who are at stake. >> thank you. ms. patrick, you're recognized for five minutes. >> i appreciate what the secretary is doing with construction of omi and coming up with a strong internal audit system. however, i must express i am skeptical about how that is going to work. we lerner testified that have the whistleblower protection act but it is not enforced. my concern first of all is that we have heard so much testimony in this committee about a culture of secrecy, a culture of retaliation, and retaliation is a huge deterrent to hearing complaints. my first question, ms. lerner, is to you. there has been retaliation against employees. i am concerned that there is retaliation against asians who might feel that -- against

theynts who might feel have been mistreated at a facility. aware of any retaliation in part because my agency's jurisdiction is to come for employees forward with retaliation complaints or disclosures of waste, fraud, or abuse or safety problems. thought a patient was being retaliated against, i don't believe we have gotten any of those cases. people come to my agency with disclosures about poor patient care where they complain about patients not getting appropriate treatment and are retaliated against themselves for having made those complaints. , wein terms of patients probably would not get those.

>> is there some kind of national hotline that v.a. atients can call with complaint? >> i don't know the answer to that. >> there are a number of mechanisms that patients now have to give us feedback about the system. they quite frankly do complain to our patient advocacy system. that is a real human being at each facility that they can go to. >> at is my concern -- at each facility. we are seeing a pattern that you have a complaint in the facility that never goes outside of that. let me throw out an idea. i am a former prosecutor, and we had a difficult time getting andle to report child abuse neglect, elder abuse, until we established a hotline where the report can be anonymous, that there would be an investigation. then we started to be able to get these reports. there was no possibility of atelier should.

-- there was no possibility of retaliation, anyway, anywhere. i don't see how we will get to the root of this without something like that in place, where there is a hotline that veterans can call if they feel they did not get the care they wanted, and that employees can call and make reports so there is no possibility of retaliation. would you consider something like that? >> in addition to the local options that veterans have, veterans -- patients can call the oig hotline today, and we are -- >> who knows that? who knows how to do that? you get my point? we will have to look at this very hard and put our veterans first. the employees are taking care of them first. i am sorry to interrupt you, but i feel very passionate about this. >> i do, and i respect that tremendously.

the department of defense has a ice.am they call it is a directive on their website. any patient or employee can go on the website and provide feedback, file a complaint, say you did a great job, and it goes to the top of the command chain. we are looking at that. it would be free to us at the v.a. to put it on our website. right now we're looking at discussions about what is the business process behind that, and quite frankly, i will take the point you are making back home and say it needs to behind in the organization. >> thank you very i yield back the balance of my time. is ourlerner, it understanding that ocs is spending a lot of time on the

whistleblower, the caseload from the whistleblowers. can you tell us what congress can do to alleviate the amount of time you are spending on that activity so you can continue to take care of the needs of the v.a. whistleblowers? >> i want to start by noting that this committee has been particularly supportive of our work. i want to recognize the staff of the oversight and investigations subcommittee for their work on this issue and their work with our agency. we consider it to be a real partnership, and we are very 'sateful for this committee support. we have also received a number of referrals from the committee and we appreciate your conference in -- your confidence in our ability. that is one thing. it is already happening. we are doing everything we possibly can to a dress v.a.

cases- to address the a the relay. v.a.ve staff to handle employee claims. but as the numbers increase, it is hard to keep up during we were at capacity before the v.a. cases overtook us, and the total number of cases between disclosures and retaliation cases now exceeds 130. and the number continues to increase pretty much daily. we are a tiny agency. we have 120 employees, more or less. we have jurisdiction with the onch act and are working now the demonstration project that this committee provided to us. we also handled disclosures, over 1200 per year. this will be a record this year with the v.a. disclosures.

and we also handle prohibited personnel practices. we are stretched pretty thin right now. >> is continue to let us know what we can do to be helpful. >> thank you. >> dr. tuchschmidt, one of the things we talked about is that some whistleblowers have provided limited patient which is allowed through special channels to deal what they perceive as problems at the v.a. when they do this, it is not a ipaa, but thesep employees are charged with policy violations. stopo we get the v.a. to with the chargers when the

whistleblowers go through the top steps to do this? -- with the charges when the whistleblowers go through the top steps to do this? >> an employee in my opinion inappropriately was put on administrative leave while that investigation was being done over concerns that the person -- ipatient information can tell you that the leadership at that facility now knows that people have a right to have information, can share that information with the osc, the oig, with congress, and it is aa file patient. we need to make sure that people across our organization .nderstand this issue clearly i wish i could say it would never happen again. i think that would certainly be

our intention, to make sure that people are more aware and more cautious about what they do. >> we will continue to try to put that message out. i yield back. custer, five minutes. >> i wanted to ask dr. tuchschmidt -- in the private sector of hospitals they have a process of quality assurance, typically a quality assurance committee where information that is shared in cases with that committee is typically by statute, protected from discovery in a medical malpractice lawsuit. as an attorney, i want to get to the bottom of whether part of the behavior we're hearing about tonight and throughout the testimony from the whistleblowers has to do with people within the v.a. trying to

protect the agency from medical malpractice lawsuits. i isf that is the case, if there something we can do statutorily -- i worked at the state level with a statute that protected quality assurance so you can have a quality improvement process going forward without all this behavior of covering their backs and blaming people that are bringing these issues forward. could you comment on that? >> i think we have, quite frankly, adequate protections in place for quality assurance documents that are covered statutorily. . cannot say we are an organization of 300,000 people. i don't know what everybody thinks when they go out and do something. but i can tell you that i would

be surprised if a concern about the release of quality might be motivating some of the concerns, particularly the retaliatory behavior, about whistleblowers. managing those situations is difficult for local management. athink we need clearly to do better job of informing and educating. again, i don't know how to say it any better. i was appalled by the stories i heard tonight. i don't think we as an organization should tolerate that. i don't think you should let us tolerate that. >> we are shocked. >> i am shocked. >> i just wanted to get at that issue. on another issue entirely, another level of shock for me was the information in the

record that we have about the clear disturbing pattern of racial prejudice. can you tell me within the organization -- first off, how does that exist in this day and age? secondly, is there some way to cope with that and make sure -- you know, in this day and age, honestly, with the progress we have made in our country, in all aspects of diversity, gender, race, , iigion, ethnic background cannot imagine with this many employees it could even begin to be tolerated, the type of documented in this lawsuit. >> i was absolutely floored. i was floored when he held up

his picture tonight. other what was in his slide and it is even more abhorrent. it is astounding that it happened at the ucla medical , amongst highly educated professionals. i don't get it. again, in an organization with 300,000 people, people do stupid things. we cannot always control that. >> but would there be any procedure or process if that was reported up the chain? >> absolutely. in my 20-something years, i can tell you that this organization has been for a long time one of the most inclusive and supportive of diversity organizations i have seen. we train people, we train people eeo and workplace harassment

issues. we have programs that support cultural diversity and cultural competency within the organization. i just -- i am astounded, quite doctor's story. quite frankly, i learned about three of these are true whistleblowers -- three of these four whistleblowers the first time i read it in the paper. we clearly need to do a better job of making sure that people can communicate their concerns. there are a lot of avenues, right? they have the osc process, they have the oig, they can come to you all. they cannoty is come to us in the organization. that is where it has to start.

with our start employees being engaged on the front line and taking a meaningful role and feeling like they can fix those things within their sphere of influence and go to people that can when they cannot. if we cannot do that -- >> we all concur that that is what we need to do, and as far as i am concerned, there are people who need to lose their positions over this. >> thank you for letting me go over. for fivee recognized minutes. >> thank you, mr. chairman. ms. lerner, dr. mitchell on the whatous panel talked about she thought was a sham process. have you seen anything like that in your investigation? i am going to ask mr. bachman. >> have seen that in some

investigations and are taking a closer look at those when we see them. these types of investigations can be difficult to prove as pretext for retaliation sometimes, but we are seeing that as an emerging trend, and it is something we are focusing we aremaking sure that gathering all the evidence we can to see exactly why was this undertaken. >> thank you. dr. tuchschmidt, are you aware 2013, the. program in stop the lying program? >> i am not sure which program you are talking about because stop the line is part of the lien technology process. there are many -- >> as i understand it, it is a way to encourage v.a. employees when something is going on where

you would expect certain quality. >> many have adopted it on their own. but as part of our patient safety program, we have a stop the line timeout process. and this is, particularly true in our procedure based areas. any employee who feels something is not like before something is happening to the patient can call a timeout, stop the line, and say i disagree with that. that could be the doctor, the nurse, the housekeeper in the operating room that stops the line because they feel something is not right, and the line stops until it is resolved. >> does the v.a. keep track of how many times this initiative is invoked? >> not to my knowledge. >> our reports selected? -- are reports selected? >> not to my knowledge. chiefsve a report of 60

of anesthesia around the country invoked a formal communication to v.a. with the stop phoneline line initiative regarding a policy that would change how surgical care was delivered, and the chief of communication was sent to the v.a. secretary, the undersecretary for health, and the principal deputy for the undersecretary for health. >> so it would be the former principal deputy. >> yes, you are the acting, i understand. despite being told otherwise by not officials, they have received a response. >> i am unaware, but i am happy to take that back and find out. >> could you? we were briefed that they did get a response, and then subsequent to that we were told by them that they did not.

i would like to know what the response is. could you please get that to me? >> i have no idea, but i will get a response for you and for them if they did not get one. >> do you know how often the v.a. gets a letter from more than 50 department heads about a problem? >> i do not. >> it seems like that would be a worse -- it would seem like that would be worth a response to me. >> it would be atypical, yes. >> there are many atypical things you have to explain, and i appreciate your policy to the veterans of this country. i saw your emotion when you first gave your statement. >> thank you. >> but you see what a huge problem we are trying to deal with here. expressingf are severe emotion, and it is hard for us to sit here without

saying what is going on and how do we fix this, and you are in the same boat. we need some dramatic change, and we are all hoping this new secretary and legislation that we are working on will make a dramatic change within the v.a. i worked at the v.a. for 20 with the comment you made earlier about these things being isolated incidents, it is not. it is not isolated incidents. i went to the meeting and a whole mess of them are telling me this. it is a systemic problem. we need to deal with it. >> i appreciate your sentiments. walls, you are recognized, five minutes. >> thank you, chairman, and thank you all for being here. i concur with dr.

roe. it does not appear to me that people have come to grips with this. your feeling of being sick and disillusioned, that is how i feel and that is how my veterans feel. a generation of good work has been erased. this is about care, about getting trust, working on things like seamless transition, making sure that programs from wind and veterans are there. i have been sitting here for and trying to prove to be a good actor on this. the question i have is, what is going to change? what is your definition of unacceptable? >> i think, quite frankly, the bottom line for me from the time i went to medical school until the patienten, has gotten what he or she believes they needed? and it has to be quality, it has to be safe, and effective.

that is the bottom line. >> we try to work around this and what the fix is? we have to diagnose first before we can prescribe the treatment on this. on we have to move forward how to get it fixed. so today the letter comes out, and it is very clear that the acting secretary made it clear, as i told the workforce, retaliation against whistleblowers or any employee who makes a suggestion or reports what is a violation is unacceptable. was it not unacceptable to secretary shinseki? was there anyway that you got the impression it was acceptable than and not now? >> that was not apparent. >> what changed today? >> we do have new leadership. acting secretary gibson has stepped up. he is out in the field going to medical centers. pull the process

up to the department level where he can personally supervise it. his engagement in this is phenomenal. >> one of the complaints about how the v.a. works and the insular nature of it is that they can just outlive people. they might be thinking that they can outlive mr. gibson and he will be gone, secretaries can be gone, presidents will be gone, and whatever. this pains me -- this breach of faith -- and i have set up here for eight years and are your most staunch supporter. but i will be your staunch critic. it floors me that i do not believe with one fiber of my being that you are going to get this right. if i were sitting there asking what are you going to do about it -- i want us to pull this back in and i want to do the data and know that the data is true.

i ask you, ms. lerner, is there a way to do this? is there a way to have third-party event -- to have third-party evaluation? we have to stand in front of voters, the constituents, and the veterans every two years. how do we restructure this? are we trying to fix a broken system that is beyond repair on trying to get this accountability? >> i said before i am an optimist. >> i am, too. i supervised a high school lunch room for 20 years. >> you are very brave as wel l. >> i am an optimist, but what proof is there? the line,ation is on too, if you say it is going to be fixed. >> my job is to shed light because that is the best disinfectant. the whistleblowers are shedding light on where the problems are.

the next step is to see some action. and what we have heard in the last several weeks from the new leadership i believe is encouraging. >> eight weeks ago i asked what is the problem with the rochester v.a., and people told me you are right and you deserve an answer right away. why has there not been an answer on that? a member of congress was told they would get an answer about what is wrong with their local gotten ani have not answer. >> i am not here to defend the v.a. i have had a pretty ringing indictment of what is going on, but i think there are steps that -- expediting of review of whistleblower complaints -- if we can get the expedited review in place and whistleblowers can see quick action, that sends a powerful message not just to the

individuals involved but to the facility. if there is disciplinary action when someone retaliates against actions we need to have and positive words. >> and you think we can get it? >> i am going to do my best to follow up on the promises made to me. i expect this committee will join me in continuing to do oversight. that is our job. i am happy to come back in six months and report back to you on what actions we have actually seen taken. but one of the problems i think has been that we have gotten the warnings from the whistleblowers about where the problems are, but they have been hidden from probably v.a. leadership because omi has been saying no harm no foul. there is no violation, and no regulation that has been violated.

>> i would suggest total elimination of the omi. >> but whatever replaces it -- whether it is the oig, whatever the entity is that is beestigating, there needs to a review triggered whenever there is a finding of a problem. it has to go higher than what ever the investigating entity is. the second thing, there has to actualok to see whether harm has occurred. what we have been seeing is that the omi says yes the allegations are true, but there is no harm here. but they do not look to see whether patients have been harmed or not. in the brockton case, the omi only looked at the three patients that the psychiatrist reported on. this is aatrist said widespread problem throughout the facility, but the omi only looked at those three patients,

did not look to see if it was more widespread. >> i am beyond my time. thank you, mr. chairman. i apologize. >> mr. whewell's camp -- mr. huelskamp, you are recognized for five minutes. >> it was stated when he repeatedly brought up doctors doing 3.5 hours of work during workday, eight hour the explanation he received was, "this is the v.a." that is not a common practice. that is not an expectation. >> can you tell me how you know whether that is true or not? >> i think there was a briefing on capacity in the organization. >> the v.a. briefing said their data was no good, words to that effect. the second question, in

reference to mr. davis, if ms. lerner can shed some light on this -- you indicated folks from your association had met with white house deputy chief of staff ron neighbors and secretary gibson about these issues. were you in on those meetings? >> i was. mr. bachman was as well. >> mr. davis does note that he believes that deputy chief of staff of the white house ron na bors leaked his whistleblower complaint. did you visit with mr. nabors about this possibility about what the problems and penalties might be for doing such an action? >> my meeting with mr. nabors did not focus on this matter. i don't know anything about it, quite frankly? my guess is that -- and i am guessing here -- that mr. nabors was trying to intervene to help

and not to leak someone's name in a definitive kind of way. >> this goes to the highest levels. the allegation tonight was that the very folks at the highest levels that we are relying on were violating whistleblower laws. , want to ask dr. tuchschmidt how do you inform employees about their rights under whistleblower protection? >> we have training that electronicake in our education system, so there is online training available to all employees, and supervising training as well. >> is it mandatory? >> how often do they -- ? your data is sometimes questionable. following up on a few more things, dr. tuchschmidt, in

2013, the director of the v.a., created a health care system where he received an $8,985 bonus. based on the testimony from dr. be anynight, will there effort to pull back or rescind her bonus? >> i cannot comment. i don't know. >> let me ask you about another one. similarly, the director including the phoenix v.a. health care system, the director received a bonus. based on what we heard tonight about retaliation, discrimination, will there be an effort to rescind that bonus? our performance awards are tied to a performance evaluation. that was done based upon the knowledge at the time that that was completed.

we don't really believe we have the authority to go back once those are done and change apartments -- and change a prior .erformance evaluation or > >> the cbo for member service received a bonus of over $7,600. an effort, or will you allow these bonuses to remain as well? >> we don't go back and change performance evaluations once they are completed. recordse 1241 patient that were falsified, how many records do you have to falsify in order to be fired as an employee. >> i would hope you would not have to falsify any. one would not be acceptable. 1241, i cannot comment on the

specifics of that case. one.u said it is the lady next to you has verified 1241 times, and they are still working, serving veterans. your response is they still get to keep their job. >> i would be happy to arrange and share the details of that with you. >> i would be happy to hear that. to i think the public needs know, are you serious about that, still giving out bonuses? i yield back, mr. chairman. v.a. haschschmidt, the come and briefed our staff and said that the v.a. believes they have up to one year to be able bonus back. is it your testimony that even though fraud was committed, that a bonus is still something that

individuals should receive based on the information that was known at the time? >> i think you are getting out of my swim lane. i do not know the technical answer to the question, but i am happy to go back and get that answer for you. >> is called fraud and it is illegal. >> i understand. recognized for five minutes. >> thank you. >> i want to continue mr. huels kamp's question about line of recovery, and what ms. lerner included in her testimony, that in 2012 a whistleblower was -- i think that establishes the danger and the threat and the potentially bad outcome for the veteran when we do not have the right information for the anesthesiologist in this case.

the whistleblower reports these concerns to the alabama v.a. . during that 2012 gri evaluation, he does this again. he cuts and pastes information on to veterans' medical records. ,nd then you get omi involved and far worse than previously believed, the review determines the pulmonologist engaged in , inc. 1241 pasting separate patient records. saying you cannot comment on this. it just defies common sense in what all of us would expect from , that you would just say this person would be fired. i don't know why ms. lerner can tell us all these details and

this is now public record, and you cannot tell us, you cannot tell the people in alabama, more importantly the veterans there, what is happening. and if we are talking about creating a culture of accountability, what does it say to the surgeon who is a whistleblower, to the anesthesiologist that this pulmonologist is still working? what does it say about what happens when you have the courage to take the risk to your up and alert superiors to malpractice or malfeasance within the v.a.? the signal you send to everybody tonight is don't take that risk, the we are not going to do anything. the sin could not be more glaring than that documented by ms. lerner. is there anything you can say? what would it cost you or the v.a. or the federal government to go out on a limb and say we

are going to fire that person, he or she should not be working for us? earlier, there are reasons why i feel i cannot go into details here. there are still active investigations going on into a lot of these issues by the oig. if i put enough details out there, somebody can make connections back to individuals. again, these are complicated issues. >> i don't know how it is complicated. let me ask this follow-up question for ms. lerner. in your testimony you say osc requested and has not yet received information from the v.a. to determine if the 1241 instances of copying and pasting result in any adverse patient outcomes. requested at? >> i'm sorry, i don't know the exact eight. >> more than a week?

more than a month? >> i am quite sure. understand, dr. tuchschmidt, why you cannot answer our questions about why this home of knowledge just is still working. but certainly you can answer the question about responding to their request about how this affected patient outcomes. >> i don't know what the response is. i did not know they had not received something but i can take care of that and find out why a response has not been received. --an say to you that i think it is our intention, i am committed in the job that i am now acting in to try and address these issues. >> i am not convinced that you are going to do it, and i don't know you so you cannot take this personally, but it has been reflected in testimony that we have heard from almost every v.a., longive in the

enough to know that we have a major problem with accountability and performance. i am not convinced that we will be able to turn around. everything was lined up from the previous panel about the kind of problems and for how long it existed and what is needed to change this. then we hear from the v.a. essentially a non-answer it sends the message to us and to every employee of the v.a. that you do not take this seriously. you can say you are appalled, outraged, deeply disappointed, but that has all been said before. what we need now is this is what we have done, are currently doing, what we will be doing. i have not heard any of that. ,he previous head of the v.a. heard of veterans

seeking mental health appointments and could not attain one, but we finally learned through the vha audit was the truth. the doctor's response was not let -- was let's not get into assigning blame. in other words, letter not be consequences, let's not change anything we are doing. i have to register that deep profound disappointment that i have in so many others today. ask the acting secretary to change the culture now. >> message heard. >> thank you. >> mr. kaufman, you are recognized for five minutes. dr. tuchschmidt, based on the testimony provided by the whistleblowers here tonight, it appears that the same unethical tactics are occurring. numerous v.a. medical centers across the country. this would seem to indicate there is a universal policy in

place against whistleblowers that is well-known among all the supervisors throughout the country. do you have an explanation for this? i don't believe there is any policy or a collusion to suppress whistleblowers among the top leadership of the organization. in fact, i think the organization has said today, particularly secretary gibson, that we intend to do something about that. the message has clearly gone out to everybody in that june 13 letter that there are consequences for retaliation. we have to go through a process when those complaints come in. so that we are treating people fairly and we know both sides of the story and we have facts before we take action. but i think the organization, that the secretary speaks for

the organization. i think the commitment is there and i have to take him at his word. it is clear from all of the comments here and from all of you, we have an enormous problem. we are a huge organization. it is not going to change overnight. are all inpatients, but it is going to take some time to fix some of these fundamental issues. it is going to start with leadership, and we have a new acting undersecretary. we have a nominee. we will have a new undersecretary for health at some point, and i hope a new principal deck the undersecretary. principalope a new deputy undersecretary. >> you have been a part of leadership in the v.a. for quite some time. how long have you been a part of leadership? >> over 20 years. >> and you testified tonight that this is the first time you have become aware of the

problems that were brought forward by the whistleblowers tonight. >> i learned about these whistleblowers mostly by reading them in the papers, yes. >> so you have been in for 20 years. you have been in leadership in the v.a., and you have been in leadership for 20 years and you are just totally oblivious to what is occurring around you in terms of all of the problems. it really was not until it has become a national story that now you are suddenly aware of them. i think that that really speaks to the culture of the v.a. and the problem. and that if not for the whistleblowers who have come forward, we would never be aware of the magnitude of the problems that exist today because the leadership or the lack thereof never bought these issue -- never brought these issues forward. let me ask you -- are you a

veteran yourself? >> no, i am not. >> let me tell you, the military don't thinkhis, i you can lead starving troops to a chow hall. beingw secretary, after confirmed by the senate, which i believe he will, if he has folks enioryou in se leadership, he is sending a message he is not serious about change. ms. titus, you are recognized for five minutes. >> thank you, mr. chairman. i want to go back to my concern about the emergency room at the las vegas hospital. they spoke with me at my invitation, talked about the problems there, the lack of leadership, the manipulation of schedules, and those who work directly for the v.a. versus those who are contracted from

the private sector who get special treatment. get indon't want them to trouble because of my initiating an invitation to learn more about what is going on down there. i would ask you if maybe you cannot provide it here, what if you could let me know if they are among those cases that you have that had been filed, if anything has come out of las vegas. >> i cannot speak to specifics. we have not received any complaints from the las vegas facility. >> ok, i am glad to hear that. i would also like to ask you -- mr. davis was saying different things are comfortable for different people. some whistleblowers go to the press, some hire lawyers, and some go to a veterans at this easy group -- some go to a veterans advocacy group, and some go to congress. if someone who works at the

hospital, some doctor or somebody who works out of their feels like they want to be a whistleblower and they come to me, tell me what practical advice i give them. here is what you should do, here is how you are protected. here is who you call, here is the form you fill out. what advice do i give them? >> the first advice i would give is please refer them to us. the number one priority in our office right now is we are throwing everything we have at it. we have dedicated over half our program staff to dealing with these whistleblower retaliation complaints, so that would be the first step. once we get in contact with them, we can find out what their issues are. if for some reason we are unable to help, we can point them in the right direction. >> and they would come to you here in washington, not in nevada? >> correct, in washington. >> i yield back.

>> you are recognized for five minutes. >> thank you, mr. chairman. i will be brief. dr. tuchschmidt, i would like to know about the stop the line program that we have. the program was presented to me at my local hospital as something that was the end-all be-all of accountability for employees to step up and make a comment. and yet we have the whistleblowers who have not heard of the program. i recognize the importance of the program, it clearly it has not penetrated to the level that it was presented to me. a bit of a softball question, i admit it, but it is an important question. to give you the time to answer it. you have apologized tonight, you have spoken of accountability,

you're appalled, speechless. i was impressed several weeks another who apologized weeks ago and referred to a crisis of integrity. witnessay but for the who two weeks ago said the system was dishonest -- with frankly -- which friendly i -- you was a deferral have been with the v.a. for 20 years? >> yes. >> here is a softball for you, but it is important. have you noticed a change in the past six or eight weeks as a result of the intention -- as a result of the attention? do you believe that we are entering a new era of leadership within the v.a., regardless of who steps into the position? the time is yours on that one. >> i do. that there are many

places around this system that are phenomenal, where we have outstanding care, better care that exists in the private sector. that haveaces outstanding access. our problem, i think -- one, i agree with you that we have a crisis of integrity. how we restore that will be a slow and painful process. the clinical issues are the biggest issues, that we do not have a uniform, systematic approach to these things. so we have pockets of excellence and places that are not performing so well. the amount of activity in the four weeks i have been in this job and have had the opportunity to be aware of these problems has been outstanding. the secretary is out there. we are sending teams into the facilities. the have sent teams into phoenix three or four times to help

them, ask them what do we need. i spend my days trying to get them what they need. i can tell you 12 of those 20-something years, i was a facility director. i practiced as a clinician in the intensive care unit. i practiced there. i knew what was going on in my facility. i walked the halls. my values i wore on my shirt sleeve, and people knew where i stood on issues around integrity, around bringing problems forward, about people coming together and solving those problems. there was no doubt in my mind about what it took to make sure that the patient was the end-all and be-all of what we took care of. that is why we were all there, everyone of us. and if you were not there for that purpose, then you had better take a hike. that was clear to everybody. i don't know that i am the perfect shining example, because

quite frankly i spend many nights sitting in bed what i personally could have done differently. when could i have raised my hand? could i have pushed back harder? know that iot should have known? many sleepless nights. i don't know that i am the epitome of what it will take, but i think it will take leadership not just at the secretary level, not just at the undersecretary level, but all the way down to the service chief who owns the problem and says how can we fix it. we have a lot of great people in the organization that will step up to the plate, and i am confident we will bring in new people today to help solve those problems. >> thank you very much. >> thank you, mr. jolly. thanks to the panel. based on our hearing today, we would expect the secretary of veterans affairs to establish a long-term plan of intended actions with target dates that would determine what actions to

take against the a managers when reprisals have been found to have taken place, notifying on a periodic basis all employees of their whistleblower rights and measuring the effectiveness of such actions such as a periodic in designingloyees and lamenting a system for tracking overall whistleblower complaints, complaints for which reprisal was determined, and the complaint was settled. in addition, we recommend v.a. analyze the data periodically to ascertain whether additional steps are needed to ensure that reprisal is not tolerated. with that, i ask unanimous include extraneous materials. without objection, so ordered. thanks to both witness panels

and employees who attended. dr. tuchschmidt, one last question. is ms. hellman still on the payroll? >> i don't honestly know the answer to that question. >> does she work under your purview? >> yes, many layers down. >> that you don't know if she is still on the payroll? >> i would have to get an answer for the record. >> with that, this hearing is adjourned.

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we will also hear from taylor branch and two college football players. that is live at 2:30 eastern. requestedhouse as $3.7 billion in aid for additional border security. arizona republican david schweikert about border security challenges. we will also talk with doris securityof the border policy institute. and nick hanauer joins us. magazine, ititico" is said that pitchforks are coming.